AccountId: 011433970860
ContactId: 5c4c1058-e34e-41c1-8441-23575f3f5fce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 812159 ms
Total Talk Time (AGENT): 272013 ms
Total Talk Time (CUSTOMER): 179264 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/5c4c1058-e34e-41c1-8441-23575f3f5fce_20250418T19:53_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes, um, this is, um, [PII] calling from Celebrate Dental Independence. Um, I was calling to get a full breakdown of the patient's benefits.
[AGENT][NEUTRAL] Of course, you said your name was [PII]?
[CUSTOMER][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] Hi there, you're an appointment today.
[AGENT][NEUTRAL] OK, and do you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, give me one quick second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sorry about that um, uh, this is [PII] I'm calling from my provider's office needed to get a breakdown of benefits for a patient of mine.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, [PII], do you have the policy number?
[CUSTOMER][NEUTRAL] 02596982
[AGENT][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And the patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Uh [PII], uh, [PII].
[AGENT][NEUTRAL] OK, and then what's a good callback number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] OK, give me just one moment while I look into his policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Would
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you for calling Celebrate the moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so I have his policy pulled up. What benefits are you looking for?
[CUSTOMER][NEUTRAL] Dental.
[AGENT][NEUTRAL] OK, so I have the dental fax back pulled up. Um, were you looking for like calendar year max and deductible?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, yeah, so I'm calling because I need to get a full breakdown, uh, but starting off, uh, are we a network with this plan?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So this plan would be Carrington.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then we are we are in network or?
[AGENT][NEUTRAL] Uh, I'm not sure if you guys are in network with this plan, but if you are in network with Carrington.
[AGENT][NEUTRAL] Then you would be
[CUSTOMER][NEUTRAL] OK, we are, so, OK, um, effective date for this patient?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so it looks like the policy is active. The effective date is [PII].
[CUSTOMER][NEUTRAL] OK, annual max?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like calendar year max is 1500 per covered insured.
[AGENT][NEUTRAL] And this is not a guar guarantee of payments, just a verification of coverage.
[CUSTOMER][NEUTRAL] Deductible.
[AGENT][NEUTRAL] Uh, so calendar year deductible is 50 per cupboard insured up to 150 per family.
[AGENT][NEGATIVE] And deductible does not.
[CUSTOMER][NEUTRAL] Anything used out of either?
[AGENT][NEUTRAL] Sorry, deductible does not apply to preventative expenses.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, let me check for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and nothing has been used as of this year?
[CUSTOMER][NEUTRAL] OK, let's move on to the frequencies for the for the um sorry the percentages for the preventative, basic and major.
[AGENT][NEUTRAL] OK, so preventative is 100% of UCR.
[AGENT][NEUTRAL] Basic is that 80% of UCR?
[AGENT][NEUTRAL] Major is 40% of UCR and it looks like there's a waiting period of 12 months for major.
[CUSTOMER][NEUTRAL] For the for major? OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you said basic was at 80 and then major was at 40?
[AGENT][POSITIVE] Yes, correct. Mhm.
[CUSTOMER][NEUTRAL] OK. Endoperio and all surgery, is that under the basic or the major?
[AGENT][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] the
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Yeah, I'm sorry.
[AGENT][NEUTRAL] Endo and Pero fall under major, so 40% of UCR, and they also have the waiting period of 12 months.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oral surgery, the code D 7210.
[AGENT][NEUTRAL] Sorry, just one moment. I'm trying to find that code for you.
[CUSTOMER][NEUTRAL] Oh, no, no, that's not it.
[CUSTOMER][POSITIVE] Good thank you.
[AGENT][NEUTRAL] So it looks like for that code, there is no limitation and this code falls under.
[AGENT][NEUTRAL] 40% of UCR with the 12 month waiting period.
[CUSTOMER][NEUTRAL] OK, what about uh 2391?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh sorry, uh I think it's, let me see what what code we use for the fillings.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, try yeah 2391.
[AGENT][NEUTRAL] OK, and it looks like this falls under basic, which would be the 80% of UCR and there is a limitation.
[AGENT][NEUTRAL] Let me find that.
[CUSTOMER][NEUTRAL] I know
[AGENT][NEUTRAL] OK, and the limitation for this code is replacement of existing only if in place for 24 months.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] And also,
[AGENT][NEUTRAL] Maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] OK, let's move on to the frequencies, uh, let's start with the bye wings.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] So the frequency for bite wings is once per 12 month period.
[CUSTOMER][NEUTRAL] OK, exam, the, the comprehensive.
[AGENT][NEUTRAL] Looks like exams are 2 per 12 month period.
[CUSTOMER][NEUTRAL] Uh, panel
[AGENT][NEUTRAL] Pao once every 5 years.
[CUSTOMER][NEUTRAL] Profy?
[AGENT][NEUTRAL] Once every 6 months.
[CUSTOMER][NEUTRAL] Um, crowns, uh, dentures, and partials.
[AGENT][NEUTRAL] OK, so crowns and bridges once every 7 years per tooth, partials and dentures, once every 5 years.
[CUSTOMER][NEUTRAL] SRP and perio maintenance.
[AGENT][NEUTRAL] And I
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] And then those are the last two.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Do you have a code for those ones?
[CUSTOMER][NEUTRAL] Yeah, SRP 4341 uh perio maintenance 4910 and I need to know um what the perio maintenance is covered under.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like 43, 41 falls under periodontic.
[AGENT][NEUTRAL] Uh, let's see what that UCR is.
[AGENT][NEUTRAL] And that's 40% of UCR?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Hold on, I can tell you the limitations.
[AGENT][NEUTRAL] And then the limitations.
[AGENT][NEUTRAL] Says maximum of 1 each quadrant per 1, 24 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and then 4910.
[AGENT][NEUTRAL] Falls under periodontic as well, and that was the 40% of UCR.
[AGENT][NEGATIVE] And the limitations for this one.
[AGENT][NEUTRAL] Maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] OK, and then you did say that there's a waiting period. What about a missing tooth cloth?
[AGENT][NEGATIVE] There is a missing tooth clause for this policy.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then would you like the fax back for this as well?
[CUSTOMER][NEUTRAL] No, no, that, that's fine. One second here, sorry.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] Oh, no, you're good.
[CUSTOMER][NEUTRAL] Are are crowns paid on seat or prep?
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] OK, what is the group number?
[AGENT][NEUTRAL] The group number.
[AGENT][NEUTRAL] Just a moment, I have to go back to the policy.
[AGENT][NEUTRAL] The group number is 21769.
[CUSTOMER][NEUTRAL] OK, that is all the information that I needed. Uh, can I get a reference number for this call, please?
[AGENT][NEUTRAL] Of course, it's my first name, [PII]
[AGENT][NEUTRAL] Last initial [PII] and then today's date.
[CUSTOMER][POSITIVE] OK, thank you very much for that information um you have a great day.
[AGENT][POSITIVE] Thank you. Thanks for calling APL. Have a good day.
[AGENT][NEUTRAL] Mm. OK, bye.
[CUSTOMER][POSITIVE] Thank you bye.